Provider Demographics
NPI:1790100311
Name:CARLSON, ROBERT J (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3116
Mailing Address - Country:US
Mailing Address - Phone:612-827-5309
Mailing Address - Fax:612-827-6833
Practice Address - Street 1:10 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3116
Practice Address - Country:US
Practice Address - Phone:612-827-5309
Practice Address - Fax:612-827-6833
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist